critical“Staff did not have access to up-to-date and accurate information to provide safe care and support...assessments and supports plans had not been reviewed for some time.”
record keeping
1 finding
critical“Information about people's assessed risk were in some cases unclear due to conflicting information in their care records. Some staff we spoke with were not aware of people's assessed risks.”
incident learning
1 finding
critical“Systems to monitor accidents and incidents were not effective and did not promote learning. Audits did not fully consider any emerging trends or themes to reduce the risk of reoccurrence.”
safeguarding
1 finding
critical“The provider's systems to monitor safeguarding concerns had lapsed in 2022, but this had recently been re-established to ensure managers and leaders had oversight of all concerns.”
staff training
1 finding
critical“Approximately less than half of all support workers employed at the service had been trained on epilepsy awareness, autism awareness, challenging behaviour, mental health awareness.”
supervision appraisal
1 finding
critical“In 2022 we saw staff had received 1 supervision out of the 6 required by the provider's policy.”
governance
1 finding
critical“Systems were either not in place or robust enough to demonstrate quality and safety was consistently well-managed. This placed people at an increased risk of harm. Breach of regulation 17.”
leadership
1 finding
critical“Inconsistencies in leadership led to serious shortfalls in the provider's quality assurance processes...processes to identify risk and ensure the service was operating within the scope of regulations had not been effective.”
medication management
1 finding
moderate“During the inspection we found 2 instances where medicines had not been safely stored...People's medicine support plans did not promote safe and personalised support as these had not been reviewed.”
infection control
1 finding
minor“We found built up dirt and grime in shared bathrooms, kitchens, food cupboards and fridges.”
person centred care
1 finding
moderate“Some staff were not following people's positive behaviour support plans to ensure they followed all preventative and reactive strategies to enhance people's quality of life.”
communication with families
1 finding
moderate“One professional said, 'It can be a little challenging to get any updates from staff members about people when reviewing (their care and support). Often staff don't know much about the person.'”
staff competency
1 finding
moderate“The service supported people with a learning disability and/or autism, yet only half of the staff were trained in this area.”